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Child Inpatient Satisfaction Survey |
RCS Number: DD-HA (A) 2076 |
Survey Instructions
Answer each question by marking the box to the left of your answer.
You are sometimes told to skip over some questions in this survey. When this happens you will see an arrow with a note that tells you what question to answer next, like this:
Yes
No If No, Go to Question 1
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Please answer the questions about the child and hospital named in the cover letter. Do not include any other hospital stays in your answers.
WHEN YOUR CHILD WAS ADMITTED
TO THIS HOSPITAL
Was your child born during this hospital stay?
Yes If Yes, Go to Question 14
No
For this hospital stay, was your child admitted through this hospital’s Emergency Room?
Yes
No If No, Go to Question 5
Were you in this hospital’s Emergency Room with your child?
Yes
No If No, Go to Question 5
While your child was in this hospital’s Emergency Room, were you kept informed about what was being done for your child?
Yes, definitely
Yes, somewhat
No
During the first day of this hospital stay, were you asked to list or review all of the prescription medicines your child was taking at home?
Yes, definitely
Yes, somewhat
No
During the first day of this hospital stay, were you asked to list or review all of the vitamins, herbal medicines, and over-the-counter medicines your child was taking at home?
Yes, definitely
Yes, somewhat
No
YOUR CHILD’S CARE AFTER ADMISSION
TO THIS HOSPITAL
Do not include care received in the Emergency Room for the rest of the survey.
Is your child able to talk with nurses and doctors about his or her health care?
Yes
No If No, Go to Question 14
yOUR CHILD’S EXPERIENCE WITH NURSES
The next questions ask about your child’s experience during this hospital stay. You will be asked about your own experience during this hospital stay in later questions.
During this hospital stay, how often did your child’s nurses listen carefully to your child?
Never
Sometimes
Usually
Always
During this hospital stay, how often did your child’s nurses explain things in a way that was easy for your child to understand?
Never
Sometimes
Usually
Always
During this hospital stay, how often did your child’s nurses encourage your child to ask questions?
Never
Sometimes
Usually
Always
YOUR CHILD’S EXPERIENCE WITH DOCTORS
During this hospital stay, how often did your child’s doctors listen carefully to your child?
Never
Sometimes
Usually
Always
During this hospital stay, how often did your child’s doctors explain things in a way that was easy for your child to understand?
Never
Sometimes
Usually
Always
During this hospital stay, how often did your child’s doctors encourage your child to ask questions?
Never
Sometimes
Usually
Always
YOUR EXPERIENCE WITH NURSES
During this hospital stay, how often did your child’s nurses listen carefully to you?
Never
Sometimes
Usually
Always
During this hospital stay, how often did your child’s nurses explain things to you in a way that was easy to understand?
Never
Sometimes
Usually
Always
During this hospital stay, how often did your child’s nurses treat you with courtesy and respect?
Never
Sometimes
Usually
Always
YOUR EXPERIENCE WITH DOCTORS
During this hospital stay, how often did your child’s doctors listen carefully to you?
Never
Sometimes
Usually
Always
During this hospital stay, how often did your child’s doctors explain things to you in a way that was easy to understand?
Never
Sometimes
Usually
Always
During this hospital stay, how often did your child’s doctors treat you with courtesy and respect?
Never
Sometimes
Usually
Always
YOUR EXPERIENCE WITH PROVIDERS
A provider in the hospital can be a doctor, nurse, nurse practitioner, or physician assistant. During this hospital stay, how often were you given as much privacy as you wanted when discussing your child’s care with providers?
Never
Sometimes
Usually
Always
Things that a family might know best about a child include how the child usually acts, what makes the child comfortable, and how to calm the child’s fears. During this hospital stay, did providers ask you about these types of things?
Yes, definitely
Yes, somewhat
No
During this hospital stay, how often did providers talk with and act toward your child in a way that was right for your child’s age?
Never
Sometimes
Usually
Always
During this hospital stay, how often did providers keep you informed about what was being done for your child?
Never
Sometimes
Usually
Always
Tests in the hospital can include things like blood tests and x-rays. During this hospital stay, did your child have any tests?
Yes
No If No, Go to Question 26
How often did providers give you as much information as you wanted about the results of these tests?
Never
Sometimes
Usually
Always
YOUR CHILD’S CARE IN THIS HOSPITAL
During this hospital stay, did you or your child ever press the call button?
Yes
No If No, Go to Question 28
After pressing the call button, how often was help given as soon as you or your child wanted it?
Never
Sometimes
Usually
Always
During this hospital stay, was your child given any medicine?
Yes
No If No, Go to Question 30
Before giving your child any medicine, how often did providers or other hospital staff check your child’s wristband or confirm his or her identity in some other way?
Never
Sometimes
Usually
Always
Mistakes in your child’s health care can include things like giving the wrong medicine or doing the wrong surgery. During this hospital stay, did providers or other hospital staff tell you how to report if you had any concerns about mistakes in your child’s health care?
Yes, definitely
Yes, somewhat
No
During this hospital stay, did your child have pain that needed medicine or other treatment?
Yes
No If No, Go to Question 33
During this hospital stay, did providers or other hospital staff ask about your child’s pain as often as your child needed?
Yes, definitely
Yes, somewhat
No
THE HOSPITAL ENVIRONMENT
During this hospital stay, how often were your child’s room and bathroom kept clean?
Never
Sometimes
Usually
Always
During this hospital stay, how often was the area around your child’s room quiet at night?
Never
Sometimes
Usually
Always
Hospitals can have things like toys, books, mobiles, and games for children from newborns to teenagers. During this hospital stay, did the hospital have things available for your child that were right for your child’s age?
Yes, definitely
Yes, somewhat
No
WHEN YOUR CHILD LEFT THIS HOSPITAL
As a reminder, a provider in the hospital can be a doctor, nurse, nurse practitioner, or physician assistant. Before your child left the hospital, did a provider ask you if you had any concerns about whether your child was ready to leave?
Yes, definitely
Yes, somewhat
No
Before your child left the hospital, did a provider talk with you as much as you wanted about how to care for your child’s health after leaving the hospital?
Yes, definitely
Yes, somewhat
No
Before your child left the hospital, did a provider tell you that your child should take any new medicine that he or she had not been taking when this hospital stay began?
Yes
No If No, Go to Question 41
Before your child left the hospital, did a provider or hospital pharmacist explain in a way that was easy to understand how your child should take these new medicines after leaving the hospital?
Yes, definitely
Yes, somewhat
No
Before your child left the hospital, did a provider or hospital pharmacist explain in a way that was easy to understand about possible side effects of these new medicines?
Yes, definitely
Yes, somewhat
No
WHEN YOUR CHILD LEFT THIS HOSPITAL
As a reminder, please answer the questions about the child and hospital named in the cover letter. Do not include any other hospital stays in your answers.
Using any number from 0 to 10, where 0 is the worst hospital possible and 10 is the best hospital possible, what number would you use to rate this hospital during your child’s stay?
0 Worst hospital possible
1
2
3
4
5
6
7
8
9
10 Best hospital possible
Would you recommend this hospital to TRICARE-eligible friends or family?
Definitely no
Probably no
Probably yes
Definitely yes
ABOUT YOUR CHILD
In general, how would you rate your child’s overall health?
Excellent
Very good
Good
Fair
Poor
Is your child of Hispanic or Latino origin or descent?
Yes, Hispanic or Latino
No, not Hispanic or Latino
What is your child’s race? Mark all that apply.
White
Black or African American
Asian
Native Hawaiian or other Pacific Islander
American Indian or Alaska Native
ABOUT YOU
How are you related to the child? Do not include personally identifiable information.
Mother
Father
Grandmother
Grandfather
Other relative or legal guardian
Someone else
Please print:
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What is your age?
Under 18
18-24
25-34
35-44
45-54
55-64
65-74
75 and older
What is the highest grade or level of school that you have completed?
8th grade or less
Some high school, but did not graduate
High school graduate or GED
Some college or 2-year degree
4-year college graduate
More than 4-year college degree
COMMENT
Please think about your child’s stay at the hospital named on the cover letter. Please answer this additional question about that stay. Do not include personally identifiable information.
What could we have done to improve this hospital stay?
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THANK YOU
Please return the complete survey in the postage-paid envelope.
TRICARE Inpatient Satisfaction Survey, c/o Survey Processing
Center/IPSOS,
PO Box 5030, Chicago,
IL 60680-9858
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Matthew Kleffner |
File Modified | 0000-00-00 |
File Created | 2024-07-26 |